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Cardiovascular Diseases Chapter 4. Renal Diseases and Hypertension Chapter 5. Respiratory Diseases Chapter 6. Diseases of the Liver and Gastrointestinal Tract Chapter 7. Bleeding Disorders Chapter 8. Blood Dyscrasias Chapter 9. Endocrine Diseases Chapter Parathyroid Disease and Calcium Metabolism Chapter Adverse Drug Reactions. Section 3: Infectious Diseases Chapter Mechanisms of Infection and Host Defense Chapter Herpesviruses and Enteroviruses Chapter Human Immunodeficiency Virus Disease Chapter Bacterial Infections Chapter Our objective is to enable both students and practitioners to attain a final diagnosis and initiate the appropriate treatments.

The essential procedures of history taking, and oral or head and neck examinations, are discussed and illustrated. These are the critical first steps in correlating patient complaints and findings with abnormalities and disease entities differential diagnosis. A brief overview of the important organ systems adds to an understanding of the interactions between oral findings and overall patient health. The text has an abundance of colored illustrations to aid a clinician in defining and classifying deviations from normal as well as disease entities.

An accompanying CD-ROM contains the full text and illustrations plus problemsolving cases that accompany most chapters. This addition not only allows for testing but also reinforces the material as it applies to clinical situations. We have prepared this text in oral medicine to simplify patient evaluation and treatment, improve patient care, and prevent complications. We hope the work will help you achieve these goals. Sol Silverman Jr L. Roy Eversole Edmond L. Truelove June We would like to express our appreciation of our students and patients, who have constantly challenged our diagnostic acumen.

Special thanks is extended to Ms. Heather Kidd at BC Decker for her support and efforts in keeping us focused on the overall mission for this text, and for engineering all the aspects of this book and accompanying CD with regard to organization, the myriad of details, and formatting. The editors also wish to extend their gratitude to Drs. Rasika Naran, Perry T. Francis, Don Fowkes, and to Mrs. Maria Co-Viray for serving as examiners and patients in the chapter on physical diagnosis.

The expertise and cooperation of the contributing authors is recognized and their substantive additions to Essentials of Oral Medicine are greatly appreciated. This book is dedicated to the patients that the three principal authors have examined, diagnosed, and treated in their clinics throughout more than a century of collective oral medicine practice. These patients have endured pain, loss of function, disfigurement, and lowered quality of life from the many neoplastic, infectious, inflammatory, and neurologic diseases from which they have suffered.

We hope that we have contributed to their healing and comfort. An effective approach to the patient who requires dental care entails the following steps: 1 establishing rapport, 2 learning the chief complaint, 3 recording the history of the present illness, 4 procuring the medical history, and 5 conducting a thorough physical examination Figure Completion of these five steps provides details that collectively are known as the history and physical database, which may suggest a number of diagnostic possibilities.

The database may be compatible with a variety of disease processes, which constitute the differential diagnosis. Once a differential diagnosis has been established, a process of elimination is pursued by further questioning into the history and procuring clinical laboratory tests, cytology, biopsy, imaging studies, and other diagnostic aids. Once all necessary data have been accumulated, sufficient information should be present to determine a definitive diagnosis.

In some instances, when a definitive diagnosis is not readily apparent, therapeutic drug trials can be instituted to determine if any pharmacologic benefit is obtained. The patient must be made to feel that he or she is the most important person on your schedule, at least for the private time you have together. Some patients will be accompanied by a spouse, friend, or relative. In general, it is prudent to explain that you need to engage in a private discussion and will inform the accompanying person of everything that transpires, if disclosure of such information is not detrimental to the patient.

Of course children require the presence of their parent or guardian. Establishing patient rapport Chief complaint History of present illness Medical and dental history Physical examination. Patient approach The establishment of rapport is perhaps the most important part of the patient workup. A favorable doctorpatient relationship ensures honesty and trust and places the patient in the role of a cooperative participant in his or her oral health care rather than a passive bystander. The patient undergoing an oral medicine workup is often apprehensive, possibly suspecting that he or she suffers from a serious disease such as cancer or acquired immunodeficiency disease AIDS.

The patient who is in pain also may be apprehensive and irritable, owing to weeks or months of chronic pain with no effective treatment in sight. Kindness, reassurance, a caring approach, and honesty need to be exercised at the out-. In this day of litigation in the health care setting and particularly in light of sexual harassment issues, it is wise to leave a door open or have an assistant in the same examination room, particularly when doctor and patient are of the opposite sex. Jokes and idle banter are insulting to many people and should be avoided in the professional setting.

Procurement of the database is approached in one of two ways. A patient-generated history may be completed prior to the visit. Then, during the appointment the clinician reviews the history and enters additional notations that are gleaned during the patient interview. The doctor generates the history by direct interview, making appropriate notations throughout the oneon-one discourse. The overall format for both methods is the same.

Symptoms are subjective musings on the part of the patient. Pain, discomfort, burning, numbness, roughness, and swelling are all examples of symptoms. These are usually the first aspects of the history to be recorded. Signs are objective findings discovered by the examining clinician.

The pulse, blood pressure, a mass, ulcer, erosion, white lesion, blister, pigmentation, and red lesion are all examples of signs. Signs are usually observed in the physical examination segment of the database. Signs of disease are detected by visualization, listening auscultation , smelling, and palpation of the tissues.

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Once the symptom is noted, the clinician must further characterize this subjective finding by asking the patient to describe the onset of the symptom; its duration; whether the symptom is acute, chronic, or cyclic; the nature of the complaint; and how severe the patient believes the symptom or symptoms may be. Note the plural here; there may be more than a single complaint. This questioning constitutes that part of the history referred to as the history of the present illness. For example, a patient may complain of pain and swelling of the gingiva and may relate that the pain was first noticed 1 week earlier and the swelling has been present for 3 days.

He or she may describe the pain as constant and aching with sharp stabbing episodes that are triggered by cold; the steady-state level of pain is mild to moderate, whereas the acute episodes are severe. Another example that characterizes the chief complaint is as follows: a patient states that his or her mouth is becoming progressively dry. This dryness was first noticed about 9 months ago and within the past 2 months it has become much more noticeable.

The dryness is more problematic in the earlier part of the day, and the patient wonders if the problem could be associated with the use of an antidepressant drug that was first administered just prior to the onset of the symptoms. All of these symptomatic complaints should be recorded in the chart.

As these data are being documented, the clinician may be thinking of possible diagnoses that conform to the subjective findings; however, a differential diagnosis should not be constructed until the entire database has been completed. Chief complaint The first segment of the database procurement is the recording of the chief complaint. At this time the patient is asked the reason for reporting to the office; all responses represent symptoms.

Table 11 lists the elements of the chief complaint. In the oral medicine clinic setting, there may not be a chief complaint if in fact a. Medical history The next segment of the history and physical examination is the procurement of the medical history. This can be noncontributory, or there may be systemic conditions that are associated with the chief complaint.

Table 12 lists the elements of the medical history, which, by the way, includes the dental history. The usual childhood exanthems and infectious diseases, such as mumps, measles, rubella, varicella, and so on, are noted with verification of vaccinations, both in childhood and later, in adult years. A record of hospitalizations is recorded, obtaining information on the nature of the hospital stay and any surgical procedures that the patient has undergone.

This is followed by recording the patients drug history both current and past, noting any adverse or allergic reactions. Each drug should be listed along with dosage and daily intake. Unfamiliar drugs should be investigated, using the Physicians Desk Reference PDR or similar reference, prior to rendering any treatment. Dental history The dental history includes an assessment of past caries experience, restorative dental procedures, periodontal disease, prosthetics, and past oral surgical procedures.

Patient home care status is recorded and any habits, Table 12 Category Childhood exanthems and other diseases Vaccinations Hospitalizations and prior surgeries Current medical care Last physical examination Medications Medical History Parameter. An overview of psychosocial issues is germane to dental care, oral mucosal diseases, and facial pain conditions.

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Anxiety and dental phobias must be noted and addressed, perhaps with psychological referral and intervention. Careful observation during the interview may lead one to suspect that more serious psychological problems are present. The use of illicit drugs should be investigated with direct, unabashed questioning, reassuring the patient that such information may impact the treatment that you will ultimately recommend.

This is particularly true for patients with a chief compliant of pain. Some individuals may be malingerers, seeking narcotic or mind-altering drugs, others may be recovering addicts who do not want to be exposed to narcotic analgesics. Drug interactions are of significance in illicitdrug users. Alcohol consumption should be recorded. Heavy alcohol consumption may herald chronic liver disease with a potential for hemorrhage. A patients nutritional status should be assessed, although nutritional deficiencies are uncommon in industrialized countries.

Sugar intake in the caries-prone individual and in patients with xerostomia is of significance. Socioeconomic considerations should be discussed at the outset. Who will be responsible for remitting payment for services rendered? The treatment plan and economic alternatives should be openly discussed between doctor and patient. In addition, it should be explained that many oral medicine procedures, such as examination, biopsy, cytology, and orthotics may be covered under medical insurance programs.

Review of systems The final aspect of the medical history is a review of systems. Questions must be posed so as to reveal any diagnosed as well as undetected systemic diseases. Many patients seek dental care, yet have not seen a physician in years. It is important, as health care providers, that dentists be familiar with signs and symptoms of systemic diseases so that timely referral to a physician can occur or that precautions may be taken for patient protection.

Pertinent questions are posed for each of the major organ systems. Beginning with the cardiovascular system, the oral medicine clinician should address congenital as well as acquired cardiovascular diseases. Patients should be questioned about valvular, septal, and large vessel congenital defects, particularly those that manifest with a heart murmur.

Inquiries regarding acquired valvular insufficiency and stenosis should be made, particularly in light of potential oral microbial bacteremias. In this respect, rheumatic heart disease is the primary culprit. Atherosclerotic vascular occlusive. Asking how easily the patient develops dyspnea after walking up a flight of stairs or whether he or she needs three or more pillows to sleep should assess congestive heart failure.

During the interview, ankle edema can be noted, and later in the physical examination, jugular vein distention can be assessed, both being signs of congestive heart failure. Carotid atherosclerotic lesions can often be detected on panoramic radiographs, provided aneurysms with calcifications are dense enough to be visualized radiographically.

Further assessment of cardiac status takes place while vital signs are being taken. Renal diseases include congenital defects, glomerulonephritis, pyelonephritis, and urolithiasis, all of which can culminate in end-stage renal disease with filtration failure. Patients in the later phases of renal disease will be on peritoneal or hemodialysis. Hematuria, polyurea, and anuria are all signs of urinary tract disease. Low flank pain is a common finding in urolithiasis.

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Any of these signs or symptoms should be recorded and followed-up if the patient has not seen a physician for some time. Renal transplantation is common practice today, and kidney recipients are generally placed on immunosuppressive drugs, such as prednisone and cyclosporine for the first year after their surgery. A history of pulmonary system diseases, including upper airway lesions, may have an impact on dental care, particularly if the airway is compromised.

Upper airway diseases larynx and sinonasal tract are marked by eye, ear, nose, and throat lesions. Patients undergoing inhalation anesthesia or even conscious sedation for dental procedures may be at risk if they have asthma or chronic obstructive pulmonary disease. Asthmatic patients are often taking bronchodilator drugs and using inhalers.

A history of pulmonary tract infections, particularly tuberculosis, mycotic infections, and pneumonia poses infection control risks and also compromises the airway, owing to pulmonary granulomas or post-infection fibrosis, chronic cough, dyspnea, and history of hemoptysis. Diabetes mellitus is the most common endocrine system disease to affect humans. Undiagnosed cases may present with oral manifestations or early signs that include polydipsia, polyurea, and hyperventilation.

Diabetes may occur at an early age and be insulindependent, or it may be of adult onset and most often is noninsulin-dependent. Attending complications include angiopathy, neuropathy, ketoacidosis, and delayed wound healing. Hyper- and hypofunctioning of the thyroid and adrenal glands can also have an impact on dental care. Patients with hyperfunctioning thyroid are nervous and anxious and often manifest exophthalmia, whereas hypothyroidism is characterized by lethargy and facial edema.

Hypoadrenalcorticism is. Endocrinopathies of the parathyroid can have oral and jaw manifestations. In hyperparathyroidism, radiologic changes are seen and patients complain of abdominal cramping, bone deformities, and kidney stones caused by hyercalcemia. Neurologic disorders involve peripheral nerves, the spinal cord, and the brain.

Diseases of this system result in such neurologic deficits as paralysis, spastic movement, numbness, paresthesias, forgetfulness, and other disorders of thought and emotions. Many of the diseases that affect neural functioning are infectious, others are degenerative. Loss of muscle contractility may be of neural origin or may be the consequence of primary muscular diseases, such as the muscular dystrophy group disorders. Diseases of the bones and joints cause structural deformities of the limbs, vertebrae, and even the jaws. The arthritides affect all joints and may sometimes cause symptoms in the temporomandibular joint.

Diseases of the head and neck, outside the oral cavity proper include disorders of the sinonasal tract, larynx, hypopharynx, nasopharynx, eyes, ears, and nasal passages. Signs and symptoms indicative of disorders of the eyes include loss of vision, diplopia, visual field defects, ophthalmoplegia, and mucosal diseases of the conjunctiva. Aural diseases include cancers of the external ear, infections and tumors of the middle ear with damage to the tympanic membrane, and inner ear disorders that involve balance, hearing acuity, and auditory tinnitus.

Symptoms referable to upper airway lesions include epistaxis, nasal congestion, nasal speech, hoarseness, and numbness of facial tissues. Pain and lymphadenopthy may occur as well. The gastrointestinal system includes the esophagus, stomach, gut, and accessory digestive organs. Symptoms that indicate diseases of the intestinal tract include substernal and abdominal pain, diarrhea, constipation, hematemesis, pale stools, melena, and distention.

Liver diseases are characterized by upper right quadrant enlargement hepatomegaly and jaundice, with or without fever.


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Biliary tract diseases cause upper abdominal pain and cramping, jaundice, and malabsorptionrelated symptoms. The hematologic system comprises the bloodforming tissues, subsuming diseases of the red and white blood cells and platelets. Hemostasis is also included under this system. A history of anemia, polycythemia, leukemia, lymphoma, myeloma, leukopenia, and thrombocytopenia should be noted, as should any acquired or inherited bleeding disorders. Signs of hematologic disease include petechia, ecchymosis, gingival bleeding, pallor, hemarthrosis, bone pain, and lethargy.

The review of the genitourinary system for history of disease is, of course, different for males and females. Among females, urinary tract infections are common. Symptoms relative to the female genital tract include sexually transmitted diseases as well as cervical, uterine, and ovarian diseases. Common symptoms include dysmenorrhea, amenorrhea, vaginal discharge, genital pain, masculinization, and lower abdominal signs or symptoms.

Inquiry should be made as to whether the patient is pregnant and if so how far along. Diseases of the male genitourinary tract focus on prostatic disease, characterized by urinary retention, sexually transmitted diseases, pain, discharge, sores, and testicular diseases. Upper urinary tract diseases, such as urolithiasis, pyelonephritis, and glomerulonephritis, will have been reviewed in relation to renal diseases.

Pain, urethral discharge, and lesions of the external genitalia can be seen. Many skin diseases have oral manifestations mucocutaneous disease. A record should be made of any past treatments for skin carcinoma and melanoma. Chronic dermatologic diseases that are scaly or bullous should be noted, as should instances of acne, particularly if long-term tetracycline therapy was instituted.

The breast is a skin appendage, and any diseases, including cancer, should be noted in this portion of the history. When undiagnosed skin lesions are observed, the patient should be referred to a dermatologist. The immune system may be compromised by a variety of diseases, including leukemia and lymphoma, by. Regarding HIV infection, the patient should be questioned about risk factors and, if he or she is known to be HIV-positive, immune status markers, such as CD4 lymphocyte counts.

Earlier in the gathering of information for the database, allergies to medications will have been noted; this can be reviewed, and newly identified allergies to other substances can be added. Any history of an autoimmune disease, such as lupus erythematosus, should be noted in this section of the database. If the patient has a significant health history with a compromised status, consultation with that individuals physician is often needed.

Such consultations can be made by telephone or by written requests. Before information can be obtained from another health care worker or facility, the patient must sign a written consent and release. This may be important if one desires to order clinical, laboratory, or imaging data resources from another practitioner or health care institution. Once the medical history has been completed, the salient details should be summarized and any significant treatment precautions that are found should also be noted, beginning with those that constitute a medical alert or could lead to a medical emergency.

The next phase of database procurement is the physical examination. Physical Diagnosis of 2 the Head and Neck L. Upon completion of the history, a physical examination is conducted for the assessment of patients with complaints relevant to oral medicine problems. This examination involves assessment of vital signs and clinical evaluation of the tissues in the head and neck region, including the anatomic areas listed in Table Visual inspection, palpation, and auscultation assessments of the head and neck tissues are made in a sequential manner.

During this procedure, various anomalies or lesions are recorded in the patients chart. Recording of abnormalities can also be assisted by procurement of clinical photographs and other forms of imaging, including radiographs, computed. Table 22 lists the categories of disease that may be detected during the physical examination. Surface lesions of skin, hair, scalp, and mucous membranes of the eyes, oral cavity, nasal cavity, and larynx are usually visible.

Visualization can be direct or indirect, using a. Table 22 Lesions That May Be Encountered during the Physical Examination Physical Examination Finding Loss, fineness, scalp lesions White scales, erythema, petechiae, telangiectasia, pigmentation, scar, ulceration, bulla, vesicle, tumor White, red, or pigmented mucosa, petechiae, telangiectasia, ulceration, scar, vesicle, desquamation, tumor Soft fluctuant masses, firm movable masses, fixed indurated masses, bruit, pulsation, crepitis Asymmetry, osseous expansion, atrophy, clefts Path of opening, restricted opening, clicking, crepitis Red, white, convexity, perforation, mass Pain, hypesthesia, paresthesia, motor deficit, special sense deficit.

Vital signs Hair and facial skin External eyes lids, conjunctiva, iris Ear external, tympanic membrane Oral cavity and oropharynx Dental and periodontal tissues Temporomandibular joint Facial muscles Nasal cavity and nasopharynx endoscopy Larynx endoscopy Major salivary glands Anterior neck thyroid Lateral neck Posterior neck Supraclavicular notch Cranial nerve function. Standard physical examination Vital signs Facial skin Major salivary glands and neck Oral soft tissues Dental hard tissues Periodontal examination The patient in pain TMJ and jaws Cranial nerves Otologic examination Muscle palpation The patient with salivary enlargement or pain Cranial nerves Salivary flow Comprehensive head and neck cancer screening Oral cavity Salivary glands and neck Nasal cavity, nasopharynx Larynx The patient with a history of bleeding or purpura Bleeding time Clotting time.

It is important to establish rapport with the patient and to take time to discuss what the examination entails. Visualization of sequestered areas requires special instruments, such as the otoscope, ophthalmoscope, nasopharyngoscope, or fiber optic laryngoscope. Masses of the deeper tissue are usually detected by palpation. The stethoscope can be used with auscultation to assess the carotid artery, temporomandibular joint TMJ , and larynx. The primary elements of the physical diagnosis in dentistry are the following: 1.

The other examination procedures included in this chapter are for special purposes. Table 23 outlines the indications for more specialized physical examination procedures. Certain tray setups are used for the physical examination. The basic examination tray, head and neck examination tray, and biopsy setup are shown in Figure C Figure 21 A, Basic examination tray with otoscope, stethoscope, tuning fork, gauze, mirror, explorer, and periodontal probe; B, head and neck examination tray with fiber optic light source, laryngoscope, otoscope or ophthalmoscope, tuning fork, and nasopharyngeal mirror; C, basic biospy tray setup with anesthetic syringe, punch instrument, scalpel, scissors, forceps, and suture.

Vital signs The first phase of the physical examination is the evaluation of a patients vital signs, which include respiratory rate, heart rate, and blood pressure. Respiration Respiration rate is determined by sitting next to or standing behind the patient seated in the dental chair and looking down at the patients chest. Count the number of times the chest rises and falls for 30 seconds and then multiply by 2.

A normal respiratory rate is 12 to 15 respirations per minute. Hyperpnea occurs in acidosis when an increase in carbon dioxide exhalation occurs as a physiologic compensatory process to increase blood pH. Increased shallow respirations, tachypnea, may be encountered in anxious patients. Metabolic alkalosis results in a decreased rate of respiration.

Pulse Cardiac rate, rhythm, and strength are assessed by taking the radial or carotid artery pulse. The first two measures are objective and easy to learn; a measure of pulse strength is subjective and is learned after evaluating the pulse of numerous subjects. To undertake these measures of cardiac function, one uses digital means.

For the carotid pulse, the first two fingers are placed just anterior to the sternomastoid muscle, posterior to the larynx, and below the angle of the mandible in the region of the carotid bulb Figure Only light pressure is applied until pulsations are readily detectable. Excess adipose tissue of the lateral and anterior neck in obese patients may preclude a reliable examination, and it may be more prudent to attempt to take a radial. This is accomplished by placing the first two fingers in the slight trough produced by a tissue depression between the radius and the flexor tendons located on the ventral wrist just proximal to the thumbs thenar eminence Figure Only light pressure is exerted until pulsations are perceived.

The cardiac rate is determined by counting the number of beats during 15 seconds and multiplying by 4. Normal heart rate is 60 to 80 beats per minute. Bradycardia occurs in dedicated athletes yet can also be pathologic. Tachycardia occurs in anxious subjects and in a variety of metabolic and cardiac diseases. The rhythm is assessed after or while taking the pulse rate.

A normal pulse should be steady with equal intervals between pulsations. Rapid beats followed by delayed intervals are indicative of cardiac conduction disturbances, as may occur in myocardial ischemia and myocarditis or from various metabolic disorders. Pulse strength, as mentioned previously, is a subjective measure and is learned after repeated palpation of the carotid or radial artery on many patients. A strong pulse is indicative of high cardiac output, whereas a weak pulse occurs during low contractility. Blood pressure and body temperature. Figure 22 Placement of the fingers over the carotid artery, just anterior to the sternomastoid muscle to assess cardiac rate, rhythm, and strength.

Measuring blood pressure assesses pressure within the arteries during cardiac contraction systole and pres-. To obtain these values, one must generate an external pressure that exceeds that within the artery then slowly lower that pressure until the intra-arterial pressure exceeds the externally applied pressure, thereby opening the arteries and being able to detect the pulse as blood is again pumped through. The pressure at which the first evidence of a pulse can be detected is the upper, or systolic pressure, which normally is about to mm Hg. After detecting the systolic pressure, the externally.

This level of pressure, the diastolic, varies normally from 70 to 90 mm Hg. To measure blood pressure, an inflatable sphygmomanometer cuff is placed around the upper arm Figure For children there are small cuffs and for adults with large arms there are oversized cuffs. A stethoscope with a flat diaphragm is placed in the antecubital notch.

The precise location of the brachial artery varies somewhat, so it might be advisable to first palpate the area. B Figure 24 Blood pressure measurement. A, Pressure cuff with stethoscope over the antecubital fossa; B, sphygmomanometer showing a high diastolic pressure reading; C, digital readout gives systolic and diastolic pressures as well as heart rate. Elevated diastolic pressure is a sign of increased peripheral resistance hardening of the arteries or arteriosclerosis. High systolic pressure is also indicative of hypertension. With the stethoscope in place, the cuff is inflated to about mm Hg by pumping the rubber bulb on the sphygmomanometer.

The air release screw under the bulb must be screwed tight to the closed position turning clockwise. If pulsations are detected immediately, the pressure in the cuff must be pumped up higher until no sounds are auscultated. Turning the air release set screw below the bulb counterclockwise slowly deflates the cuff. If the screw is turned too far, the cuff will deflate rapidly and the two pressure levels will be inaccurate. Let the needle fall about 5 mm Hg every second to obtain an accurate reading. On some patients, during the interval between systolic and diastolic, pulsations cease only to resume after the pressure falls 5 to 15 mm.

This is normal. Therefore, one should continue to auscultate for the diastolic endpoint until the pressure reaches 60 mm Hg.

Cawson's Essentials of Oral Pathology and Oral Medicine - MEDGAG

Temperature is recorded using a thermometer or temperature sensitive disposable oral strips. Either of these recording devices should be inserted orally, with the tip placed under the tongue, and left in place for 1. Recall that normal body temperature is 37C Elevation in body temperature febrile state equates with fever most often associated with microbial infection.

Hair and facial skin The hair is assessed for thickness or thinness and loss. Pattern baldness in men is normal and hereditary. A focal region of hair loss is termed alopecia areata and is pathologic. Fine curly hair or lanugo is encountered in some diseases and syndromes. Diffuse loss of hair occurs in patients taking chemotherapeutic drugs for cancer. Radiation can induce temporary or permanent damage to hair follicles.

The facial skin is sun-exposed, and a variety of ultraviolet radiation or so-called actinic lesions occur on the face. These include erythematous lesions with scaly keratosis, nodules, tumors, ulcers, and pigmentation. Maculopapular and vesicular eruptions also occur on the face. The examiner easily visualizes all of these lesions. Survey the forehead, eyebrows, eyelids, nasal bridge and alae, malar region, vermilion of the lips, and chin; also, inspect the submental, anterior, lateral, and posterior neck skin as well as the external ear region.

The eyebrows are first examined followed by the skin surfaces of the upper and lower lids and then the eyelashes. The inner mucosal surfaces of the eyelids palpebral conjunctivae are examined by inverting the lids. The lower lid is easily inverted by placing the thumb or forefinger on the center of the lid skin and sliding it inferiorly.

The upper lid does not retract as easily, and to clearly visualize the mucosa, a match stick or blunted toothpick can be placed longitudinally along the upper lid and with light pressure of the finger, the lid can be rolled back over the stick. The white portion of the globe of the eye, the sclera, is covered by bulbar conjunctiva, a mucosal membrane with fine vascular channels Figure The conjunctivae are examined for dryness, erosions, telangiectasias, scars, and nodules.

A scar band that traverses the bulbar and palpebral conjunctivae is referred to as a symblepharon. A slit-like defect in the eyelid is termed coloboma.


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The iris, or pigmented ring, surrounds the black pupil and is covered by a convex transparent cornea. A slit in the iris, giving a keyhole appearance, is termed iridial coloboma. The iris can dilate and constrict, varying the diameter of the pupil, depending upon the focal distance of the eye and the amount of light.

In neurologic disorders and drug overdose, the papillary diameter is altered. An overly dilated pupil over 6 mm is termed mydriasis whereas an overly contracted pupil less than 2 mm is called miosis. The pupillary reflex is checked during the cranial nerve function assessment. The cornea is examined for opacifications, which usually represent cataracts. External eyes Visual acuity, peripheral vision, visual fields, pupillary reflex, and retinal integrity funduscopy can be tested when conducting the cranial nerve assessment.

At this point in the physical examination, only the. Ears Cartilage gives shape to the external ear Figure Its structure helps to funnel sound waves into the external auditory meatus. The outer curvature is the helix, which terminates inferiorly as the lobe. The cartilage flap just anterior to the external canal is the tragus. Skin cancers can arise on any of these sun-exposed areas, especially the superior helix or pinna. Examination of the tympanic membranes TM or eardrums requires the use of an otoscope Figure This visualization instrument consists of a batterycontaining handle, a light source, a magnification lens, and a funnel-shaped speculum.

Since individuals have external ear canals of varying diameters, the ear speculums vary in size. To allow visualization of the TM the external auditory meatus must be free of cerumin earwax. A Q-tip will usually suffice, although in some patients, small ear curettes must be employed to clear the canal of wax. To examine the TM, the pinna should be grasped with the thumb and forefinger and pulled up and back. The speculum is inserted slowly and gently into the canal with a slight anterior angulation. The canal does not extend straight at a perpendicular angle to the side of the head.

The speculum is inserted just short of the hub, and at this point, the examiner looks through the lens. If the TM is not readily visualized, the speculum can be rotated and angulated slightly while the examiner continues to gaze through the lens. The membrane is whitish and taut, like the head of a drum Figure The latest edition of this popular book continues to provide a highly visual step-by-step guide to the practical management of a wide variety of presentations seen in clinical dental practice.

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Essentials of Dental Radiography and Radiology, 5th Edition. Now in its fifth edition, this comprehensive textbook of dental radiography and radiology for undergraduate dental students, postgraduate students and qualified practitioners looks at both traditional imaging methods and new modalities. A new author also has been added to this edition. Customer service. My account. Follow us.

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